This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Monday, October 06, 2008

Mind and brain

Dr. Alvaro Pascual-Leone, from our Department of Neurology, kindly sent me this link to a lovely column written by Harvard Medical Student Ishani Ganguli, on her blog Short White Coat, which is posted on the Boston Globe's White Coat Notes.

He, in turn, was prompted to comment:

Basically, given the insights on brain plasticity as an intrinsic property of the brain across the lifespan, it seems that the nervous system might best be viewed as a continuously changing structure of which plasticity is an integral property and the obligatory consequence of each sensory input, motor act, association, reward signal, action plan, or awareness. In this framework, notions such as psychological processes as distinct from organic-based functions or dysfunctions cease to be informative. Behavior will lead to changes in brain circuitry, just as changes in brain circuitry will lead to behavioral modifications.

Leading to the conclusion that, "Psychiatry and neurology do need to come closer together (again), and perhaps we should be thinking of departments (or institutes) of brain health and well being, rather than psych and neuro departments."

I recall similar statements being made several years ago by the former Dean of HMS, Joseph Martin, himself a neurologist. I wonder how psychiatrists and neurologists reading this would react to this hypothesized convergence of the two fields.

For that matter, since even those specialists really don't know for sure, how about the rest of you? Any thoughts, er, feelings, er, instincts, er, analysis on the matter? It makes sense to me, but what do I know? If Alvaro is right, whatever I do know is highly changeable anyway!

6 comments:

Anonymous
said...

This is a remarkably insightful column from a medical student. I would wager that many practicing neurologists and psychiatrists have not yet connected these dots.I am interested because just yesterday my husband and I were discussing the explosion in diagnoses of bipolar disorder, (including one in our 20+ niece, of which we are skeptical). We agreed that modern psychiatry is at the stage where the rest of medicine was in the 60's and 70's, before the spectacular advances in gene sequencing and molecular biology were made. I predict those advances are yet to come in the brain, and at that time we will look back at some of our current psychiatric diagnoses and laugh.As for merging the two depts, I think the time is coming but not yet here; the basic science research is not quite there yet.I fear there would be large "personality" conflicts between the practitioners of these two vastly different specialties, leading to mistrust which would hamper future collaboration.

Discipline frontiers are the least explored, but theoretically most productive areas of science. Many scientists - like most humans - play it safe and stick to what they know within the frames of reference that they have learned. They poke at the sides, dig in the middle, and usually come up with a lot of what they expected to find. Job security is achieved by niche carving, not risk-taking. But the great scientists are unifiers.

The slow appreciation of understanding humans as evolved and variable organisms, faced with particular behavioral and biological adaptive pressures over millions of years, has held back the science of psychology. We can assign DSM codes for pathology, but we tend to ask very little about why humans are vulnerable in particular ways. Moreover, we rarely travel out of the Western world to test hidden assumptions about the 'normative'. If we want to understand plasticity, we have to gain a better understanding of variation.

I know from my own experience that psychiatry and neurology are inextricably linked. I had a stroke a number of years ago, and shortly following it a bout of depression. The depression was a direct result of the stroke and what followed it. It would have been highly informative to have a psychiatrist who was informed about neurology and the results of strokes.

Marcel Mesulam (a previous BIDMC faculty member) is considered by many to be the father of Cognitive and Behavioral Neurology. We have followed his lead and have established the Division of Cognitive and Behavioral Neurology at the Mount Sinai School of Medicine.

The schism between neurology and psychiatry in the early twentieth century, the original integrated ambitions of early clinical neuro-psychiatrists are being realized by the rapprochement facilitated by neuroscience in the late twentieth century. Indeed, two fundamental forces are making the comprehensive approach of neuropsychiatry to mental/brain disease compelling. First, there is increasing appreciation of the spectrum complexity of mental/brain disease states (ie, many neurologic states have important psychiatric features, and the reverse) and as psychiatry moves toward etiologically based nosology, there is increasing recognition that the same neural circuitry underlies clinical syndromes with previously distinct neurologic and psychiatric classifications.

This is an encouraging discussion. As a family member of someone with a mental illness, I have long been dismayed at the schism within psychiatry itself that split the care domains of the discipline in two. New patients are often asked outright if they are seeking "meds" OR "therapy." The implicit message is that the thinking, feeling mind is distinct from the physiologic body. Patients have suffered as a result. My husband's illness wreaked havoc for years until we found the miracle of a psychiatrst that does BOTH meds and therapy. They are a rare breed. We saw first hand how effective integrated "mind/body" treatment can be.

I agree, excellent column, interesting reactions. Integrative views (also from other disciplines) very helpful. However, another problem within psychiatry might be -and this is a European view- that a focus on DSM does provide reliabilty but other classification systems such as ICD-9/10 (which might be more subjective) and theorems might add important bits to better understand an individual patient as well as a condition.